No one in their right mind will say one year [of fellowship training] is as good as two years. That would be folly. On the other hand, that’s not the question. The question is, “Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?”
—Timothy Buchman, PhD, MD, director, Emory University Center for Critical Care, Atlanta
Given the recent push for more outpatient treatment of less-critically-ill patients, many observers say the increased acuity of hospitalized patients—with more comorbidities—only exacerbates the mismatch between supply and demand. Making matters worse, providers are not evenly distributed throughout the country, with many smaller and rural hospitals already facing an acute shortage of intensivist services.
As a result, many hospitalists have been forced to step into the breach. According to SHM’s 2012 State of Hospital Medicine survey, 83.5% of responding nonacademic adult medicine groups said they routinely provide care for patients in an ICU setting, along with 27.9% of academic HM groups.
“So we have hospitalists who, either by choice or by default, care for patients who they may or may not be fully qualified to manage,” Dr. Siegal says. Practically speaking, he and his coauthors assert, the question of whether hospitalists should be in the ICU is now moot. The real question is how to ensure that those providers can deliver safe and effective care.
Experience vs. Training
Currently, internists who have completed fellowships in such specialties as pulmonary medicine, nephrology, and infectious disease can complete a one-year critical-care fellowship to obtain board certification. Experienced hospitalists have questioned the requirement that they instead complete a two-year fellowship, with no consideration given to the relevant clinical experience and maturity gained after years of hospitalist practice. In addition, they argue, it is logistically and financially unrealistic to expect a large cadre of experienced hospitalists to abandon their practices for two years to pursue critical-care training.
But Dr. Baumann says subpar internal-medicine residency requirements deserve much of the blame for offering inadequate training. “Critical care is a blend of critical thinking skills and procedural skills. Both of those are diminished tremendously in the current programs for internal medicine,” he says. “It’s really an indictment of our current training of internal-medicine residents now.”
SCCM, for its part, is sticking to its guns, albeit more quietly. When asked for comment, a spokesman issued a carefully worded statement that reads, “The paper reflects the society’s concerns regarding workforce shortages and the realities of today’s environment.”
The SHM/SCCM proposal makes sense provided that hospitalists are realistic about the types of patients they’ll see, says Timothy Buchman, PhD, MD, director of Emory University’s Center for Critical Care in Atlanta. “No one in their right mind will say one year is as good as two years. That would be folly,” he says. “On the other hand, that’s not the question. The question is, ‘Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?’”
Dr. Siegal
Derek Angus, MD, chair of critical-care medicine at the University of Pittsburgh Medical Center and lead author of the 2000 study chronicling the intensivist shortfall, is more ambivalent. “Hospitalists and intensivists have to work hand in hand. In many ways, they are the two groups that run inpatient hospital medicine,” he says. In that respect, sorting out and streamlining training pathways might be a good idea.